26 June 2010

No trouble with this diagnosis: perforated peptic ulcer. Most awesome physical exam ever. I wondered if he was faking it, since he had a history of chronic abdominal pain, but the fever and tachycardia convinced me it was real.

Enjoy these impressive images. Even the scout image was awesome:

This a lateral view of the abdomen, and check out those air-fluid levels! In case you are not familiar with these films, what you are seeing is the fluid in the abdomen (which should not be there) layering out with the exceptional amount of free air inside the abdomen which most definitely should not be there. It may be easier to see if you turn the image on the side:

And on the CT itself, you can see the incredible amount of air in the abdomen. Man, that is impressive. I wonder whether it was under tension and hissed audibly as it came out.

The mortality for this sort of thing is incredibly high. Last time I checked, he was doing well in the ICU. Some people have nine lives...

16 comments:

Probably tilting at windmills here, but who ordered the CT, and why? I will not be surprised to learn that the surgeon on call requested/demanded it, but for the non-physicians out there, the presence of air in the abdomen ("free air") mandates an operation to find and fix the source of the escaped air, or the situation is >90% lethal. Even worse, the CT shows the presence of enteral contrast- when that stuff leaks into the peritoneal cavity (where the air is), it can cause a serious reaction that makes the surgery more difficult and the clinical course more dangerous.Obtaining a CT adds delay and cost to a patient presentation that requires urgent surgery, and adds little to the management of the patient.

I don't understand why a patient's history of abdominal pain made you wonder if he was faking it. Was there something else about this case that made you doubtful? (I once had mysterious abdominal pain for several months; it turned out to be metastatic cancer. But no one seemed to think I was faking my pain along the way, as far as I could tell.)

In this case I odrered the CT. Suffice it to say that he had a complicated abdominal surgical and non surgical history, and that I was concerned he had something bad. True, a plain film would have obviated the need for CT, but let's be honest: the utility of plain films in undifferentiated abdominal pain is low. So with someone clearly ill, I went straight to CT, which is not much slower these days.

As for the chronic abd pain, again, there was a history of multiple hospitalizations for pain management, known ulcer disease and a recent workup which was negative. There was enough real disease there that i needed to check it out, but enough chronicity and opiate dependence that i wondered whether it was faked. You can never assume, and I am glad that I did not!

Seriously-- somebody told this sick guy to sit in the corner and drink his contrast dye- then wait a couple of hours for the contrast to transit- then get the CT, wait for radiologist to roll out of bed or take the donut out of his mouth to read the CT- serious delay.

SF- I inferred from your presentation that this case proceeded in the typical way- plain films followed by the fancy $high study (CT). Given his history (so your title is not quite correct- there just about always is a story), getting the CT as a first order of business is not unreasonable, but then the question becomes, "Why the plain films?" I'm not trying to hassle you, just trying to understand the logic of a colleague in a different specialty.And, yes, the air often does hiss out under pressure when the belly is opened. And, no, the mortality should not be that high- typically this occurs in young healthy people, guys more more than gals for some reason, and the only one I remember losing was 83 years old and very sick before he perforated. Prompt surgery is highly effective and has some morbidity but minimal mortality in otherwise reasonably healthy folks.

While I agree with the underlying sentiment of our plastic surgery colleague, I condemn the tone of his posts. There always is a story, and if he is a true plastic surgeon, he has no business dealing snark at the specialty of radiology. Pot, meet kettle.

One more thing, for medical trainees-the best screening study for free air in the abdomen is not abdominal xrays, it's an upright chest film. It's not 100% sensitive, but will pick up clinically relevant amounts of free air due to the techniques used. The xray techs use higher energy in filming the belly due to higher water content density, so they can burn through a small amount of sub-diaphragmatic air. If your patient presents with sudden onset of diffuse steady abd. pain and has a firm or rigid abdominal exam, an upright chest film will get you a Dx and enough ammo to call the surgeon. If you are lucky enough to have a surgeon with grey hair, he will not request a CT, but take the patient directly to the OR for repair.

Thanks JB!I had the same questions while reading the story, as to why a plain film had not been ordered.I thought working at a place low on resources (so called 'third world') since I've been taught to rely mostly on X-rays, maybe this was just my way of looking at things.

Interesting to know that a chest film is more sensitive for air under the diaphragm. I did not know this.

Nevertheless it was interesting for me from an academic PoV to see CTs of air under the diaphragm.

All of you medical marvels seem to have missed that the first two images are not "plain films" -- they are taken on a scanner table. Also, there is no po contrast (from what I can see). In my ER too, 3 view abd takes about the same amount of time as a CT (and is often read faster, as they are in different queues.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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